Running Head: SOAP NOTE
Running Head: SOAP NOTE
SOAP NOTE 1- DEPRESSION
Name of Instructor:
Course Title:
Due Date:
IDENTIFYING DATA
A.D is a 55-year-old Hispanic male who came to the clinic accompanied by one of his daughter due to feeling hopeless and depressed more each day, feeling muscle tension. Both are worried with this condition, and are looking for a close are of of his situation
CHIEF COMPLAINT: “I notice I feel more depressed everyday.”.
FAMILY HISTORY
Mother- passed away 2 months ago, of a Myocardial Infarction. Father alive- history of Colon cancer, patient has 1 daughter healthy with no medical history. Patient has a brother, current with diabetes mellitus type 2. No other conditions reported between those family members.
PERSONAL HISTORY
The patient equation has enjoyed good health throughout his life. He has never been troubled by anything and has been able to handle all the challenges that come his way. He has been able to establish social networks that help him during difficulties. However, the patient in question has been living an isolated life. There is a possibility he has not been getting the support he had before. This possibly worsened his mental status resulting in depression.
MEDICAL HISTORY
That was a point in the past when the patient broke his arm in a minor accident. It is an event that it’s believed to have caused him stress. This is because it made him hard to work for himself as he is used to. His absence from the workplace could have contributed to his feeling of depression. As a person known to love his work, this accident likely caused the depression case in question.
SOCIAL HISTORY
The patient is not a social person. He prefers to be alone in the majority of cases. He is also known to be a private person with his issues. It is suspected there is a possibility that he is undergoing an issue he is afraid to communicate with others (Palgi, Shrira, Ring, Bodner, Avidor, Bergman & Hoffman, 2020). This is why the patient must be approached with care to diagnose his issue and medical conditions.
OCCUPATIONAL HISTORY
Deficient in question has been productive in most of his years. His occupation has been more office-based; therefore, he has spent most of his time indoors. There are a few scenarios where the patient was subjected to fieldwork. As a less going person, the feedback could have gone better with him. He was pushed to the Limit, and at some point, he felt like quitting his job.
PAST PSYCHIATRIC HISTORY
The best psychiatric history of the patient is shallow and needs more information. The limited data provided makes it difficult to ascertain a psychiatric history.
HISTORY OF PRESENT ILLNESS
Patient has been depressed for a couple of months. The patient wanted to seek medical advice and support, but the current case of depression has not allow him. Today came accompanied by his daughter, due to as per patient, he is aware that every day he feels more depressed, hopeless, feeling with muscle tension and constantly. Patient denied any suicidal ideation, but report feeling really bad. This is why the patient needs further medical attention to manage his medical condition. The patient is in direct need of help because of his disturbed mental status. This is why his case has to be considered objectively and treated as the cause of his depression.
IMPRESSIONS
From the diagnosis, the patient seems ready for any medical treatment, he will be subjected to. If it were therapies, the patient would be ready to go through all necessary therapies to recover from his mental status (Strawbridge, Carter, Marwood, Bandelow, Tsapekos, Nikolova & Young, 2019). If the patient has to be treated through medication, he is also ready for all the processes.
PRIMARY DIAGNOSIS
— Depression : A group of conditions associated with the elevation or lowering of a person’s mood. A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.
According to the DSM5 (American Psychiatric Association, 2013). Patient presents with more than five of the following symptoms:
Combination of biological, psychological, and social sources of distress.
The persistent feeling of sadness or loss of interest.
Changes in sleep, appetite, energy level, concentration, daily behavior, or self-esteem.
Depression can also be associated with thoughts of suicide.
Anxiety may occur as a symptom of clinical (major) depression.
Feeling muscle tension as cause of the stress caused the depression.
Isolation person don’t involve in social activities.
DIFFERENTIAL DIAGNOSIS
1. Social Anxiety Disorder
Focus of the fear involves concerns over being embarrassed and negatively evaluated by others.
Panic sensations are cued by anticipated and actual exposure to social and evaluative situations.
2. Separation anxiety disorder: Anxiety sensations are cued by perceived and actual separation from family members, rather than fears of being negatively evaluated or criticized by others.
3. Panic Disorder: High anticipatory anxiety across various social situations. Recurrent, unexpected panic attacks in the absence of phobic cues. Patients may interpret their intense physical symptoms as threatening or dangerous.
PLAN:
Labs will be drawn: -TSH, -CBC. Exams: ECG.
Safety: -Patient must not be alone, due to suicide risk. This patient has had depression for months. If his sad state persists, the patient can begin thinking about committing suicide.
Pharmacological Treatment: Celexa to 60 mg daily which patient states she has used in the past with good results. The possible side effects are: Headache, nausea, diarrhea, dry mouth, increased sweating, feeling nervous, restless, fatigue, or having trouble sleeping (insomnia).
REFERENCES:
Palgi, Y., Shrira, A., Ring, L., Bodner, E., Avidor, S., Bergman, Y., … & Hoffman, Y. (2020). The loneliness pandemic: Loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. Journal of affective disorders, 275, 109-111.
Strawbridge, R., Carter, B., Marwood, L., Bandelow, B., Tsapekos, D., Nikolova, V. L., … & Young, A. H. (2019). Augmentation therapies for treatment-resistant depression: systematic review and meta-analysis. The British Journal of Psychiatry, 214(1), 42-51.
